Cancer and Emergency Medicine: Setting the Research Agenda Workshop

Overview

Hospital-based emergency departments (ED) evaluate and manage patients with a wide variety of oncologic emergencies, including febrile neutropenia, spinal cord compression, and acute pain. Because increasing numbers of patients are treated with outpatient treatment regimens, EDs often are the first place patients turn to when they have a complication or unexpected worsening of their condition. EDs must quickly evaluate clinical, laboratory, and radiographic tests; and they often are required to manage complex critical conditions. This complexity sometimes is increased when cancer patients present to the ED with few or no clinical records. Despite this, the ED must quickly stratify patient needs, determine appropriate treatment, and identify the most appropriate care setting (e.g., hospital admission versus outpatient).

Both knowledge gaps in cancer care guidelines and operational challenges exist, and these and other factors may lead to delays in life-saving care, treatments that are less cost-effective, and avoidable hospital admissions. The Cancer and Emergency Medicine: Setting the Research Agenda workshop featured expert stakeholders who were asked to identify gaps in the science and discuss how a research agenda could improve cancer care in the ED environment. The workshop also evaluated current opportunities and challenges in this area, and how best to design new and effective interventions to improve the outcomes of cancer patients in the ED.

Purpose

The aim of the workshop was to identify research opportunities and determine scientific priorities for issues related to oncologic emergencies managed in the ED. The workshop had three overall objectives:

Identify established cancer and ED databases that can be used for epidemiologic studies on oncologic events. Identify gaps in data availability to improve scientific knowledge of cancer care in the ED.

Review the state-of-the-science for key oncologic emergencies, including febrile neutropenia, breakthrough pain, and dyspnea/cough, focusing on current practice, gaps in evidence, and barriers to translation.

Workshop Summary

On March 25, 2015, the Office of Emergency Care Research (OECR) in the National Institute of General Medical Sciences (NIGMS) and the National Cancer Institute's (NCI) Epidemiology and Genomics Research Program (EGRP) convened a working group to identify research opportunities and scientific priorities related to oncologic emergencies managed in the emergency department (ED). Participants included clinicians and researchers working in oncology, emergency medicine, and palliative care as well as other representatives from NCI, OECR, and the National Institute of Nursing Research (NINR).

Below is a list of research questions identified during each of the workshop sessions that were used to inform the manuscript.

Session 1: National Data on Cancer Care in the Emergency Department

The prevalence of all cancers in the United States is about 13.7 million cases. The most common cancers are prostate, breast, lung, and colorectal cancers, and melanoma. Data were presented about ED use in patients with cancer, using the Centers for Disease Control and Prevention's (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and the Agency for Healthcare Research and Quality's (AHRQ) Nationwide Emergency Department Sample (NEDS). ED visits by patients with cancer make up about 3 percent of all ED visits; however the admission rate for this group of patients is 55 percent, compared with an admission rate of about 16 percent for the general ED population. The most common chief complaints were shortness of breath and abdominal pain. Using national Medicare claims data, it has been demonstrated that in the 6 months before death, ED utilization increases. It is predicted that only 50 percent of cancer patients will enroll in hospice care prior to death, and this does not increase the closer the patient is to death.

Research Questions:

How can we improve the quality and availability of epidemiologic data to study ED utilization by patients with cancer?

How do we define a "cancer-related ED visit" or who a "cancer patient" is in the emergency care environment?

How can we use the electronic health record to better capture ED diagnoses and quality data?

Can a cancer-specific field added to the NHAMCS be used to obtain better data?

How are cancer patients sent to the ED? What role does their health system, oncologist, or primary care doctor play in these visits?

What is the relationship between data generated from cancer-specific ED patients and data from the general ED population?

What is the role of free-standing EDs in these research questions?

Can data collected about ED utilization by cancer patients be harmonized with other common data elements, such as the efforts supported by the NINR and NCI?

Do ED interventions improve oncologic emergency outcomes?

What is the role of ED observation units in the care of cancer patients as compared to the general population?

Session 2: Febrile Neutropenia: Current Practice, Gaps in Evidence, and Barriers to Translation

Febrile neutropenia (FN) occurs in 10–30 percent of chemotherapy, and the mortality rate is 3–10 percent. Several guidelines have been developed nationally and internationally. The median time to antibiotic delivery in the ED varies greatly, and guideline recommendations regarding timing are inconsistent and vague. It is challenging to deliver antibiotics within some of these measures in busy EDs, but the question is: Does timing matter or is antibiotic selection what is key? Delayed antibiotic administration in FN seems to be related to longer hospital stay, but the effect on mortality is not clear. There are lots of potential confounders, and the effect of severity of illness needs to be measured. Severity of illness is confounding in that the sicker patients tend to get earlier antibiotics, and these patients also tend to have worse outcomes, which may lead to the erroneous conclusion that antibiotics cause worse outcomes. Studies from in-patient data demonstrate that in low-risk patients, antibiotics reduced non-routine discharge and in-hospital mortality. In high-risk patients, there is no association between treatment and outcomes. There also is widespread variation in the use of guidelines for FN, and therapies of uncertain value (such as granulocyte-colony stimulating factor [G-CSF]) are widely utilized. Neutropenia in solid tumors and blood cancers are very different situations, and risk stratification is very important. The time to receive results from a blood test should be part of a hospital's core measures.

Research Questions:

As has been shown in the cases of myocardial infarction and stroke, EDs are systemically capable of delivering very rapid interventions. However, the question is whether early antibiotic administration for FN is the key factor in patient outcomes. We need better data on whether early antibiotics (e.g., within 1 hour in the ED) are really needed.

What are the ED barriers that prevent the prompt administration of antibiotics?

What are the different definitions of FN that EDs are using?

Are there markers (other than neutrophil count) for which patients should receive early antibiotics?

What is the ideal disposition of the non-neutropenic patient with fever?

Have existing risk-stratification tools been validated in the ED? What are the barriers to implementing risk-stratification tools in the ED?

Can we perform a number-needed-to-treat (NNT) analysis?

Are there point-of-care biomarkers for FN that could be used earlier than a complete blood count (CBC) differential?

Is there a role for other markers (e.g., procalcitonin) for risk stratification?

Is there a relationship between time to antibiotics for FN and ED crowding?

Session 3: Acute Events in ED Cancer Care

Pain is a leading reason for ED visits by cancer patients. Despite this, there is little research on ED cancer pain and few published studies. Patients often have a mixed type of pain—nociceptive and neuropathic—which makes it more difficult to treat. There is no consensus on definition of breakthrough pain, and it is unclear which tools are best for assessing its severity. Overall, there seems to be no clear difference in effects between morphine, oxycodone, and hydromorphone; frequent ED re-evaluations are needed, and titration orders are useful.

Shortness of breath accounts for 12 percent of cancer patients' chief complaints when presenting to the ED. Dyspnea can be tumor- or treatment-related and requires quick assessment. Medicare data show that pulmonary embolism (PE) is underdiagnosed in the ED and that 35 percent of those with a PE have a prior cancer diagnosis. In one study of unexpected deaths following ED visits, the complaint of dyspnea had one of the highest risk ratios. Working group attendees also identified spinal cord compression, seizures related to brain lesions and thrombosis as oncologic emergencies presenting to the ED with evidence gaps.

Research Questions:

What is the impact of cancer pain on ED utilization?

What are the barriers, skills, and attitudes of emergency care providers in the treatment of cancer pain?

What is the impact of ED use on quality of life and longevity?

Can EDs take best practices for the treatment of sickle cell pain and apply them to cancer patients with pain?

Are non-ED breakthrough pain methods valid and feasible in the ED environment?

Can we develop clinical rules for cancer patients with dyspnea?

How can we incorporate patients into decision making?

What are the best interventions for dyspnea?

Is there a standard steroid regimen for spinal cord syndrome? How can we risk-stratify who needs a spinal MRI when a cancer patient presents with back pain?

What is the best approach to administering antiseizure medications in the ED for cancer patients with known or suspected brain lesions?

Are there racial or socioeconomic gaps in the treatment of cancer patients?

Palliative care is a subspecialty of emergency medicine. There are about 113 ED physicians who also are trained in palliative care, and several emergency physicians now lead this field. One recent randomized controlled trial allocated patients with advanced cancer in the ED patients to either early referral to palliative care or usual care. There was no difference in longevity, which should help allay fears that palliative care results in a shorter life. The American College of Emergency Physicians 2013 Choosing Wisely campaign already encourages the early referral of appropriate ED patients to palliative care or hospice. There are four ways to die (sudden death, organ failure, frailty, and terminal illness), and each has its own trajectory. Most EDs in the United States do not have access to a hospital-based hospice care service, but there are community hospice providers in most communities. NINR supports studies of efficacy and is keen to support quality pragmatic trials in this area.